The Health Sector Support Investment Project (HSSIP) in Cameroon is currently implementing Performance-Based Financing (PBF) in public, private and faith-based organization (FBO) facilities across 26 districts in the Littoral, Northwest, Southwest and East regions of Cameroon covering a total population of approximately 3 million. The objective of the PBF pilot is to enhance the quality and quantity of health care by paying health care providers and regulatory bodies based on their performance, as measured against predetermined targets, and formalizing this financing by a contract between the service provider and a purchaser. The intervention aims to increase providers’ accountability with regard to their mission and give them the autonomy and financial incentives necessary to achieve these targets, in particular by enhancing motivation among health personnel.
Cameroon is currently implementing a large-scale impact evaluation to investigate the effects of the PBF pilot on health outcomes. While the impact evaluation is based largely on quantitative analysis using baseline and end line surveys, the impact evaluation team proposed to introduce a qualitative component to the overall evaluation to probe deeper for explanations or explore specific issues that are relevant to the piloting of PBF in Cameroon.
Within the context of the PBF pilot and impact evaluation, a midterm qualitative study was conducted. The PBF Cameroon midline qualitative study focused on two primary objectives: (i) to capture experiences in the piloting of PBF at the central, regional and district level (perspectives of decision-makers, policymakers, and providers); and (ii) to capture experiential elements of health service delivery at the operational level (perspectives of community leaders and members).
The midline qualitative study was conducted from July 2013 – September 2014. A total of 128 interviews (112 in-depth interviews and 16 focus group discussions) were collected across four regions of Cameroon: the Anglophone-dominated Northwest and Southwest regions and Francophone Littoral and East regions from January to March 2014. In-depth interviews were conducted with central, regional, and district-level health officials in addition to health providers and leaders at PBF-participating health facilities in addition to civilian leaders of communities served by PBF health facilities. The focus group discussions were held at the community level with female adults who resided within communities served by PBF health facilities. The in-depth interviews and focus group discussions focused around experiences and perspectives of stakeholders regarding their reactions and perceptions of PBF implementation in the targeted regions.
The midline qualitative data collection aimed to answer two separate but complementary sets of research questions that addressed the learning objectives of the study:
1. What has been the experience of piloting performance-based financing at various administrative and operational levels of the health system in Cameroon?
2. What has been the experience of health service delivery for health workers and community membersduring the first two years of performance-based financing?
Key findings from the midline qualitative study indicate that respondents, both service providers and regulatory agents, expressed the strong desire for continued implementation of the PBF program. Specifically, the study found that PBF has resulted in increased collaboration among the various stakeholders; whether it be between regional/district supervision teams and health facilities (in particular private health facilities), or between health facilities and the community members they were serving. In addition, management tools and procedures used in PBF (such as quarterly business plans, the “outil indice” for balancing expenditures and revenues, and individual performance evaluations of facility staff) led to enhanced transparency and accountability in resource management. These positive effects also contributed to increased satisfaction among both providers and patients.
The study also identified obstacles. The most common obstacles encountered were (i) initial reluctance and adjustment of health facility staff to the program requirements; and (ii) obtaining initial buy-in for PBF and support of government health officials and health facility managers, particularly prior to the first payment of PBF subsidies when participants questioned if the Government would actually be able to implement the program as intended.
While those affected by PBF efforts have certainly voiced their desires for Cameroon to continue with the PBF program and roll it out throughout the entire country, it remains to be seen how sustainability of the program will be achieved. In hand with that sustainability is the question of will there be continued success and improvements demonstrated by health sector stakeholders as the PBF program progresses.
Despite these challenges, the results of the midline qualitative study nonetheless yield a strong picture of how implementation of PBF was carried out and perceived across the country and amongst the spectrum of stakeholders working within or affected by PBF programming in Cameroon’s health sector. From central to community levels, the PBF program – and its strong supervisory nature –enhanced accountability and transparency with improved health staff attitudes, enhanced quality of care, better reporting, increased health facility financial and operational autonomy, and strengthened collaboration between health sector stakeholders and health facilities as well as between health facilities and communities.
Questions that emerge from the midline qualitative study include whether or not the strong positive reception towards and reported improvements attributed to the implementation of PBF by the key informants of this study will continue or possibly stagnate with the continuation of the PBF program in addition to whether such progress would be seen with the possible end line of the project.